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Trouble sleeping? Behavioral therapy can help

4/30/2018 by Dr. Craig Sawchuk and John Mack, LICSW

Not getting a good night's sleep? You're not alone. Difficulty falling asleep, fragmented sleep, early awakening and sleep that doesn't restore us are common problems. As many as 15-30% of adults experience sleep issues at any given time. 

Sometimes our sleep cycle may get off track, whether it's due to stress, a change in sleep habits, or going through a medical issue. Thankfully, it usually rebounds, either on its own or after we make some minor adjustments in our habits or the stress or medical issues are resolved. 

However, for some, sleep problems may persist, leading to problems associated with insomnia. About 10% of people meet the criteria for insomnia, which usually is defined as disruptions in falling asleep, staying asleep or waking early for at least three nights a week over a three-month period. Unaddressed sleep problems can lead to difficulties functioning in almost every aspect of our lives and can have detrimental effects on our health. 

When our sleep doesn't restore us, we tend to change our habits to make up for this lack of restful sleep, such as: 

  • Increasing caffeine use during the day
  • Taking more frequent and/or longer naps
  • Going to bed earlier or trying to sleep in longer
  • Using electronics, such as TV, tablets or smartphones, during the night as distractions

While these habit changes make sense, they quickly become part of the insomnia problem. Tossing and turning result in more time in bed without sleeping. Worry and frustration start to build about not being able to sleep. Unfortunately, the brain begins to associate the bed and nighttime with sleeplessness. 

Cognitive behavioral therapy for insomnia (CBT-I) is a highly effective treatment that can lead to long-lasting beneficial improvements. In fact, the American College of Physicians recently recommended CBT-I as the first-line treatment for chronic insomnia. It's a straightforward approach that can be delivered in a variety of ways — self-help, internet, apps, individual or group. 

CBT-I doesn't necessarily focus on how insomnia started, but rather on how sleep problems are maintained. It helps people learn skills and change habits to reassociate the bed with nighttime and sleep, with the goal of reducing the amount of wakeful time during the night. 

Among the elements of CBT-I are:

  • Sleep hygiene
  • Stimulus control
  • Sleep restriction
  • Challenging negative thoughts
  • Relaxation training or stress management

Sleep hygiene involves changing your sleep habits and sleep environment to maximize the likelihood that your body is ready for sleep, such as: 

  • Making the bedroom dark, quiet and cool
  • Reducing daily caffeine use
  • Removing all electronics from the bedroom
  • Reducing or eliminating daytime naps and limiting sleep to nighttime
  • Establishing a routine time for going to bed and waking up

When sleep hygiene isn't enough, stimulus control can be very effective in helping people reassociate the bed with nighttime and sleep using strategies such as: 

  • Using the bedroom only for sleeping and sexual activity — no reading, watching TV, using electronics or even spending time in your bedroom during the day. 
  • Going to bed only when sleepy, rather than just feeling tired. When we're sleepy, our head tends to bob and our eyes are heavy. These signs tell us our body is ready to call it a night. 
  • Getting out of bed if you're lying awake for longer than 15-20 minutes. Go to another room, such as a living room, keep the lights low, and only engage in quiet activities, such as listening to light music, practicing relaxation or reading something boring. Return to bed only when you're sleepy. 
  • Keeping a regular wake-up routine. Get up at the same time each morning, even on weekends, holidays and days off. 

Sleep restriction helps reduce the amount of wakeful time in bed and promotes a stronger association between the bed, nighttime and sleep by: 

  • Tracking the amount of time you spend in bed and the amount of time you actually spend asleep. For example, you may go to bed at 10 p.m., toss and turn from 2 a.m. to 4 a.m. and get up at 6 a.m., for a total of eight hours in bed, but only six hours of sleep. 
  • Moving your bedtime later and limiting the time in bed to the actual time spent sleeping. For example, you go to bed at midnight and wake up at 6 a.m., giving you six hours of sleep. 
  • Waking up at the same time each day, while maintaining good sleep hygiene and continuing to practice getting out of bed when you're not sleeping. 

As you start to sleep more solidly through the night, then you can gradually start going to bed earlier. It may take some practice until you find the optimal sleep schedule. 

Other CBT-I skills include:

  • Learning ways to challenge nighttime negative thoughts and worries, such as "I must get eight hours of sleep in order to function". 
  • Practicing relaxation skills, such as deep breathing and progressive muscle relaxation. 
  • Learning stress management techniques, including time management and problem solving, to help reduce stress during the day. 

Here are some more resources to help you improve your sleep:

  • CBT-I therapy. Individual and group therapy is available through Employee and Community Health (ECH). Ask your care team about your options. 
  • CBT-I Coach. This free app was developed by the Veterans Administration to help users learn CBT-I skills. 
  • Sleep Healthy Using the Internet (SHUTi). This evidence-based, online treatment teaches CBT-I skills; there is a fee for users. 

CBT-I takes time and patience in order to be effective. The good thing is that nighttime always comes, so there is always an opportunity to practice, implement and refine these skills. 

Dr. Craig Sawchuk is a clinical psychologist in ECH's Division of Integrated Behavioral Health (IBH). He is the co-chair of IBH and co-chair of professionalism within the Department of Psychiatry and Psychology at Mayo Clinic's campus in Rochester. 

John Mack, MSW, is a licensed clinical social worker in ECH's Division of IBH.